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Case Reports in Medicine


Volume 2014, Article ID 564908, 5 pages
http://dx.doi.org/10.1155/2014/564908

Case Report
Pulp Revascularization in Immature Permanent Tooth with
Apical Periodontitis Using Mineral Trioxide Aggregate
Katsura Saeki,1 Yuko Fujita,1 Yasuhiro Shiono,1 Yasuhiro Morimoto,2 and Kenshi Maki1
1
2

Department of Pediatric Dentistry, Kyushu Dental University, 2-6-1 Manazuru, Kokurakita-ku, Kitakyushu 803-8580, Japan
Department of Oral Diagnostic Science, Kyushu Dental University, Kitakyushu 803-8580, Japan

Correspondence should be addressed to Kenshi Maki; k-maki@kyu-dent.ac.jp


Received 13 February 2014; Revised 24 April 2014; Accepted 24 April 2014; Published 14 May 2014
Academic Editor: Jukka H. Meurman
Copyright 2014 Katsura Saeki et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Mineral trioxide aggregate (MTA) is a material that has been used worldwide in several clinical applications, such as apical barriers
in teeth with immature apices, repair of root perforations, root-end filling, pulp capping, and pulpotomy. The purpose of this
case report was to describe successful revascularization treatment of an immature mandibular right second premolar with apical
periodontitis in a 9-year-old female patient. After preparing an access cavity without anesthesia, the tooth was isolated using a
rubber dam and accessed. The canal was gently debrided using 5% sodium hypochlorite (NaOCl) and 3% hydrogen peroxide
irrigant. And then MTA was packed into the canal. X-ray photographic examination showed the dentin bridge 5 months after
the revascularization procedure. Thickening of the canal wall and complete apical closure were confirmed 10 months after the
treatment. In this case, MTA showed clinical and radiographic success at revascularization treatment in immature permanent
tooth. The successful outcome of this case suggests that MTA is reliable and effective for endodontic treatment in the pediatric
dentistry.

1. Introduction
Immature permanent teeth with apical periodontitis or an
abscess are generally treated by apexification [1]. However,
revascularization procedures have recently been recommended to treat immature permanent teeth with necrotic
pulp tissue and/or apical periodontitis or an abscess.
Mineral trioxide aggregate (MTA) is a material used
worldwide in a variety of clinical applications, such as an
apical barrier for teeth with immature apices, repair of root
perforations, root-end filling, pulp capping, and pulpotomy
procedures [29]. In this paper successful revascularization
treatment of an immature mandibular right second premolar
with apical periodontitis in a 9-year-old patient using MTA
was described.

2. Case Report
In June 2012, a 9-year-old Japanese girl was referred to private
clinic by a general dentist for detailed examination of a
gingival abscess in the mandibular right second premolar.

The medical history of the patient was unremarkable, and


there was no relevant family history of medical or dental
abnormalities. An extraoral examination revealed swelling in
the buccal region and the patient complained of spontaneous
pain. Furthermore, an intraoral examination revealed a gingival abscess in the region of the mandibular right second
premolar (Figure 1(a)). The percussion test was positive.
Radiographic findings showed enlargement of the periodontal ligament space, along with extensive radiolucency
in the periradicular region in the area of the mandibular
right second premolar as compared with the mandibular left
second premolar (Figures 1(b) and 1(c)). The pulp vitality test
was negative. The clinical diagnosis was acute periradicular
periodontitis of the mandibular right second premolar with
pulpal necrosis.
The patient underwent oral surgery at Kyushu Dental University Hospital. The reason for hospitalization was
because she was not able to eat for gingival swelling and spontaneous pain. During hospitalization, she received an intravenous drip containing an antibiotic. She left the hospital 6
days later and was referred to our clinic. Postsurgery intraoral

Case Reports in Medicine

(a)

(b)

(c)

Figure 1: (a) Preoperative intraoral photograph showing a gingival abscess in the mandibular right second premolar. (b) Panoramic X-ray
showing extensive radiolucency in the periradicular region in the mandibular right second premolar compared with the mandibular left
second premolar. (c) X-ray showing an immature open apex and enlargement of the periodontal ligament space and extensive radiolucency
in the periradicular region in the mandibular right second premolar.

examination showed no abnormalities on the gingiva of the


mandibular right second premolar (Figure 2(a)). However,
the talon cusp of the mandibular right second premolar was
fractured (Figure 2(b)). Without using anesthetic, the tooth
was isolated with a rubber dam and accessed. Upon entering
the coronal aspect of the root canal, hemorrhaging into the
pulp chamber was observed (Figure 2(c)). A file of 10 K size
was inserted into the canal. The length of file is 10 mm.
And the patient reported discomfort, indicating potential
survival of residual vital pulp tissue. The hemorrhaging in
the coronal portion of the canal was gently irrigated; then
the area was debrided using 1.5 mL of 5% sodium hypochlorite (NaOCl) and 1.5 mL of 3% hydrogen peroxide [2, 10].
No instrumentation was performed. Next, MTA (Pro-Root
MTA, Dentsply Sankin, Tochigi, Japan) was packed into the
canal using MAP system (Dentsply Sankin, Tochigi, Japan)
(Figure 2(d)) and the access cavity was closed with glassionomer cement (Fuji IX GP, GC, Tokyo, Japan). An X-ray
obtained after the procedure confirmed MTA placement in
the canal (Figure 2(e)).
Six months later, an intraoral examination showed no
abnormalities in the gingiva of the mandibular right second premolar (Figure 3(a)), while an X-ray photographic
evaluation showed formation of a dentin bridge in the
mandibular right second premolar (Figures 3(b) and 3(c)).
Ten months later, an intraoral examination showed no
abnormalities of the gingiva in the mandibular right second
premolar (Figure 4(a)), and X-ray images revealed formation

of a dentin bridge and thickening of the canal walls in the


mandibular right second premolar (Figures 4(b) and 4(c)).
We think it is important to follow up this tooth, but she
had moved. It is too far for her to refer to our clinic. So we
could not follow up her.

3. Discussion
Apexogenesis is done is in immature teeth when part of the
pulp tissue inside the root canal remains vital and apparently
healthy. This procedure allows continued physiological development and formation of the root end.
In cases with an immature root with a large apical
foramen, pulp infection associated with an apical lesion does
not always indicate pulp necrosis, as seen in our patient,
likely because the pulp at this stage is vital enough and
has extremely high healing ability. Those procedures have
been shown to result in increased thickening of the canal
walls by deposition of hard tissue and encourage continued
root development in affected immature permanent teeth
[1013]. Continued root development of revascularization
of immature permanent necrotic teeth depends on whether
Hertwigs epithelial sheath survives in cases of apical periodontitis/abscess. Hertwigs epithelial sheath has important
role in root development and shape and may be involved in
regulation of the differentiation of periodontal ligament stem
cells with the formation of cementum.

Case Reports in Medicine

(a)

(b)

(c)

(d)

(e)

Figure 2: (a) Intraoral photograph showing no abnormalities of gingiva. (b) The central cusp of the mandibular right second premolar had
been fractured. (c) After controlling hemorrhage, viable tissue was observed in the canal because insertion of a K-file evoked a sensation. (d)
Placement of MTA in the canal. (e) Postoperative X-ray photograph showing MTA placement in canal.

(a)

(b)

(c)

Figure 3: (a) Intraoral photograph showing no abnormalities of gingiva. (b) Panoramic X-ray photograph showing the formation of a dentin
bridge in the mandibular right second premolar. (c) X-ray shows that radiolucency became less radiolucent in the periradicular region and
the formation of a dentin bridge in the mandibular right second premolar.

Case Reports in Medicine

(a)

(b)

(c)

Figure 4: (a) Intraoral photograph showing no abnormalities of gingiva. (b) Panoramic X-ray showing the formation of a dentin bridge and
thickening of the canal walls in the mandibular right second premolar. (c) Panoramic X-ray showing the formation of a dentin bridge and
thickening of the canal walls and establishment of the periodontal ligament space and lamina dura in the mandibular right second premolar.

MTA is a cement material with excellent biocompatibility


and good sealing capacity that is able to produce hard
tissues such as dentin and cementum [14]. It is used for
apexification and sealing of communication between the root
and periodontal tissue, such as in reverse root canal filling and
perforation repair [15]. However, there are few reports of its
use for pulp revascularization using MTA [11, 16]. Calcium
hydroxide formulations are typically used for apexogenesis
and poor sealing capacity [17]. Furthermore, formation of a
necrotic layer immediately beneath the pulp can occur and
the procedure must be changed to a pulpectomy in some
cases due to spreading inflammation, as it does not provide
an adequate biodefense mechanism against even a limited
bacterial invasion [18]. Accordingly, we used MTA in this
case. Generally, the root of a tooth with pulp revascularization
is smaller than a mature tooth and is characterized by
more rapid calcification of the pulp than that seen after a
conventional apexogenesis procedure, as noted in the present
case [11]. Chen et al. [11] demonstrated five types of response
of these immature teeth with infected necrotic pulp tissue and
apical periodontitis/abscess to revascularization procedures:
type 5, formation of a hard tissue barrier in the canal between
the coronal cement plug and root apex using MTA. The
present case was consistent with type 5. In cases with an
immature root with a large apical foramen, pulp infection
associated with an apical lesion does not always indicate pulp
necrosis, as seen in our patient, likely because the pulp at this
stage is vital enough and has extremely high healing ability.
It has been reported that pulp revascularization was induced
by removing infective material from the root canal and applying calcium hydroxide past MTA [10, 12]. Traditionally, in
the clinical protocol for revascularization treatment, several
kinds of antibacterial medicine were used. But, recently, it
reported that a single-visit pulp revascularization protocol
can be a favorable treatment for partially necrotic immature
permanent teeth using MTA as a pulpal seal [16].

Accordingly, for immature tooth with a pulp infection


and open apical foramen, treatment should start with pulp
revascularization and then shift to apexification if incurable,
while considering the infection to be reversible.

4. Conclusion
In the present case, clinical and radiographic evidence
showed successful use of MTA for revascularization treatment of an immature permanent tooth. More studies are
necessary to understand the mechanisms of pulp revascularization comparing different protocols.

Conflict of Interests
No potential conflict of interests was disclosed.

Acknowledgments
This study was supported in part by grants-in-aid for scientific research from the Ministry of Education, Science, Sports,
and Culture of Japan and from Kitakyushu to Kenshi Maki.

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